{"id":6049,"date":"2021-11-30T21:12:30","date_gmt":"2021-11-30T21:12:30","guid":{"rendered":"https:\/\/gentleproceduresnb.ca\/?page_id=6049"},"modified":"2021-12-14T16:11:07","modified_gmt":"2021-12-14T16:11:07","slug":"inscription","status":"publish","type":"page","link":"https:\/\/gentleproceduresnb.ca\/fr\/vasectomie\/inscription\/","title":{"rendered":"Inscription pour une vasectomie"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"6049\" class=\"elementor elementor-6049 elementor-5756\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-2d997c25 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"2d997c25\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-680d0811\" data-id=\"680d0811\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-2ff7d372 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"2ff7d372\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-5821a10a\" data-id=\"5821a10a\" data-element_type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-52b16841 elementor-widget elementor-widget-heading\" data-id=\"52b16841\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Inscription pour une vasectomie\n<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-4b944b66\" data-id=\"4b944b66\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-2d07ba85 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"2d07ba85\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-wide\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-45fead83\" data-id=\"45fead83\" data-element_type=\"column\" id=\"page-form\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-3d8d0bb4 elementor-widget elementor-widget-text-editor\" data-id=\"3d8d0bb4\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\tCompl\u00e9tez le formulaire d\u2019inscription ci-dessous pour la vasectomie sans scalpel.\n\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-546a2279 elementor-widget elementor-widget-text-editor\" data-id=\"546a2279\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\tNous vous rappellerons pour confirmer votre rendez-vous et r\u00e9pondre \u00e0 vos questions.\n\nMerci d\u2019avoir r\u00e9serv\u00e9 avec nous.\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-64026cfd uael-gf-style-underline uael-gf-input-size-xs uael-gf-btn-size-xs uael-gf-button-center uael-gf-ajax-true uael-gf-enable-classes-no elementor-widget elementor-widget-uael-gf-styler\" data-id=\"64026cfd\" data-element_type=\"widget\" data-widget_type=\"uael-gf-styler.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"uael-gf-style uael-gf-check-style elementor-clickable\">\n\t<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_unknown gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_27' ><form method='post' enctype='multipart\/form-data'  id='gform_27'  action='\/fr\/wp-json\/wp\/v2\/pages\/6049\/' data-formid='27' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_27' class='gform_fields top_label form_sublabel_below description_above validation_below'><li id=\"field_27_26\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Information sur le patient<\/h2><\/li><li id=\"field_27_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Nom*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_27_1'>\n                            \n                            <span id='input_27_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_27_1_3' value='' tabindex='2'  aria-required='true'     \/>\n                                                    <label for='input_27_1_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_27_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_27_1_6' value='' tabindex='4'  aria-required='true'     \/>\n                                                    <label for='input_27_1_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_27_4\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Adresse*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_27_4' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_27_4_1_container' >\n                                        <input type='text' name='input_4.1' id='input_27_4_1' value='' tabindex='6'   aria-required='true'    \/>\n                                        <label for='input_27_4_1' id='input_27_4_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_27_4_3_container' >\n                                    <input type='text' name='input_4.3' id='input_27_4_3' value='' tabindex='7'   aria-required='true'    \/>\n                                    <label for='input_27_4_3' id='input_27_4_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_27_4_4_container' >\n                                        <select name='input_4.4' id='input_27_4_4' tabindex='8'    aria-required='true'    ><option value='' ><\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Terre-Neuve-et-Labrador' >Terre-Neuve-et-Labrador<\/option><option value='Territoires du Nord-Ouest' >Territoires du Nord-Ouest<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='\u00cele du Prince-\u00c9douard' >\u00cele du Prince-\u00c9douard<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_27_4_4' id='input_27_4_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_27_4_5_container' >\n                                    <input type='text' name='input_4.5' id='input_27_4_5' value='' tabindex='10'   aria-required='true'    \/>\n                                    <label for='input_27_4_5' id='input_27_4_5_label' class='gform-field-label gform-field-label--type-sub '>Code Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_4.6' id='input_27_4_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_27_3\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_3'>Carte Medicare*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_27_3' type='text' value='' class='medium'   tabindex='11'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_27_2\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_2'>Date de naissance*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_2' id='input_27_2' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='12'  placeholder='mm\/jj\/aaaa' aria-describedby=\"input_27_2_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_27_2_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_27_2' class='gform_hidden' value='https:\/\/gentleproceduresnb.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_27_5\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_5'>Num\u00e9ro de t\u00e9l\u00e9phone principal*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_27_5' type='tel' value='' class='medium' tabindex='13'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_27_81\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_81'>Num\u00e9ro alternatif (travail)*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_27_81'>Inscrire ND si aucun<\/div><div class='ginput_container ginput_container_text'><input name='input_81' id='input_27_81' type='text' value='' class='medium'  aria-describedby=\"gfield_description_27_81\" tabindex='14'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_27_6\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_6'>Courriel*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_6' id='input_27_6' type='email' value='' class='medium' tabindex='15'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_27_7\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Contact d&#039;urgence*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_27_7'>\n                            \n                            <span id='input_27_7_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.3' id='input_27_7_3' value='' tabindex='17'  aria-required='true'     \/>\n                                                    <label for='input_27_7_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_27_7_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.6' id='input_27_7_6' value='' tabindex='19'  aria-required='true'     \/>\n                                                    <label for='input_27_7_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_27_8\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_8'>Num\u00e9ro de contact d&#039;urgence*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_27_8' type='tel' value='' class='medium' tabindex='21'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_27_85\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Comment avez-vous entendu parler de nous?*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_27_85'><li class='gchoice gchoice_27_85_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_85.1' type='checkbox'  value='Recherche en ligne'  id='choice_27_85_1' tabindex='22'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_85_1' id='label_27_85_1' class='gform-field-label gform-field-label--type-inline'>Recherche en ligne<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_85_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_85.2' type='checkbox'  value='R\u00e9f\u00e9rence d&#039;un m\u00e9decin'  id='choice_27_85_2' tabindex='23'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_85_2' id='label_27_85_2' class='gform-field-label gform-field-label--type-inline'>R\u00e9f\u00e9rence d'un m\u00e9decin<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_85_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_85.3' type='checkbox'  value='R\u00e9f\u00e9rence de famille et\/ou ami'  id='choice_27_85_3' tabindex='24'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_85_3' id='label_27_85_3' class='gform-field-label gform-field-label--type-inline'>R\u00e9f\u00e9rence de famille et\/ou ami<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_85_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_85.4' type='checkbox'  value='Publicit\u00e9 imprim\u00e9'  id='choice_27_85_4' tabindex='25'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_85_4' id='label_27_85_4' class='gform-field-label gform-field-label--type-inline'>Publicit\u00e9 imprim\u00e9<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_85_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_85.5' type='checkbox'  value='Radio'  id='choice_27_85_5' tabindex='26'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_85_5' id='label_27_85_5' class='gform-field-label gform-field-label--type-inline'>Radio<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_85_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_85.6' type='checkbox'  value='M\u00e9dias sociaux (Facebook etc.)'  id='choice_27_85_6' tabindex='27'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_85_6' id='label_27_85_6' class='gform-field-label gform-field-label--type-inline'>M\u00e9dias sociaux (Facebook etc.)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_85_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_85.7' type='checkbox'  value='Autre (svp sp\u00e9cifier ci-bas)'  id='choice_27_85_7' tabindex='28'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_85_7' id='label_27_85_7' class='gform-field-label gform-field-label--type-inline'>Autre (svp sp\u00e9cifier ci-bas)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_27_86\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_86'>Si &quot;autre&quot; veuillez svp sp\u00e9cifier :<\/label><div class='ginput_container ginput_container_text'><input name='input_86' id='input_27_86' type='text' value='' class='medium'   tabindex='29'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_27_65\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Docteur qui vous a r\u00e9f\u00e9r\u00e9<\/h2><\/li><li id=\"field_27_66\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Nom du docteur r\u00e9f\u00e9rant<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_27_66'>\n                            \n                            <span id='input_27_66_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_66.3' id='input_27_66_3' value='' tabindex='31'  aria-required='false'     \/>\n                                                    <label for='input_27_66_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_27_66_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_66.6' id='input_27_66_6' value='' tabindex='33'  aria-required='false'     \/>\n                                                    <label for='input_27_66_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_27_68\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_68'>No de t\u00e9l\u00e9phone du docteur r\u00e9f\u00e9rant<\/label><div class='ginput_container ginput_container_phone'><input name='input_68' id='input_27_68' type='tel' value='' class='medium' tabindex='35'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_27_92\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Travail<\/h2><\/li><li id=\"field_27_93\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_93'>Quelle est votre profession?*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_93' id='input_27_93' type='text' value='' class='medium'   tabindex='36'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_27_94\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Votre m\u00e9tier est-il physique ?*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_27_94'>\n\t\t\t<li class='gchoice gchoice_27_94_0'>\n\t\t\t\t<input name='input_94' type='radio' value='Oui'  id='choice_27_94_0' tabindex='37'   \/>\n\t\t\t\t<label for='choice_27_94_0' id='label_27_94_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_27_94_1'>\n\t\t\t\t<input name='input_94' type='radio' value='Non'  id='choice_27_94_1' tabindex='38'   \/>\n\t\t\t\t<label for='choice_27_94_1' id='label_27_94_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_27_40\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Informations sur la famille<\/h2><\/li><li id=\"field_27_41\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Quel est votre \u00e9tat civil actuel?*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_27_41'>\n\t\t\t<li class='gchoice gchoice_27_41_0'>\n\t\t\t\t<input name='input_41' type='radio' value='C\u00e9libataire'  id='choice_27_41_0' tabindex='39'   \/>\n\t\t\t\t<label for='choice_27_41_0' id='label_27_41_0' class='gform-field-label gform-field-label--type-inline'>C\u00e9libataire<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_27_41_1'>\n\t\t\t\t<input name='input_41' type='radio' value='Conjoint de fait'  id='choice_27_41_1' tabindex='40'   \/>\n\t\t\t\t<label for='choice_27_41_1' id='label_27_41_1' class='gform-field-label gform-field-label--type-inline'>Conjoint de fait<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_27_41_2'>\n\t\t\t\t<input name='input_41' type='radio' value='Mari\u00e9'  id='choice_27_41_2' tabindex='41'   \/>\n\t\t\t\t<label for='choice_27_41_2' id='label_27_41_2' class='gform-field-label gform-field-label--type-inline'>Mari\u00e9<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_27_41_3'>\n\t\t\t\t<input name='input_41' type='radio' value='Divorc\u00e9'  id='choice_27_41_3' tabindex='42'   \/>\n\t\t\t\t<label for='choice_27_41_3' id='label_27_41_3' class='gform-field-label gform-field-label--type-inline'>Divorc\u00e9<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_27_41_4'>\n\t\t\t\t<input name='input_41' type='radio' value='S\u00e9par\u00e9'  id='choice_27_41_4' tabindex='43'   \/>\n\t\t\t\t<label for='choice_27_41_4' id='label_27_41_4' class='gform-field-label gform-field-label--type-inline'>S\u00e9par\u00e9<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_27_42\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_42'>Dur\u00e9e de la relation:*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_27_42'>\u00c9crire \"N\/A\" si non applicable<\/div><div class='ginput_container ginput_container_text'><input name='input_42' id='input_27_42' type='text' value='' class='medium'  aria-describedby=\"gfield_description_27_42\" tabindex='44'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_27_43\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_43'>\u00c2ge du partenaire:*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_27_43'>\u00c9crire \"N\/A\" si non applicable<\/div><div class='ginput_container ginput_container_text'><input name='input_43' id='input_27_43' type='text' value='' class='medium'  aria-describedby=\"gfield_description_27_43\" tabindex='45'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_27_44\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Avez-vous des enfants ensemble?*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_27_44'>\n\t\t\t<li class='gchoice gchoice_27_44_0'>\n\t\t\t\t<input name='input_44' type='radio' value='Oui'  id='choice_27_44_0' tabindex='46'   \/>\n\t\t\t\t<label for='choice_27_44_0' id='label_27_44_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_27_44_1'>\n\t\t\t\t<input name='input_44' type='radio' value='Non'  id='choice_27_44_1' tabindex='47'   \/>\n\t\t\t\t<label for='choice_27_44_1' id='label_27_44_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_27_47\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_47'>\u00c2ge(s):*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_27_47'>\u00c9crire \"N\/A\" si non applicable<\/div><div class='ginput_container ginput_container_text'><input name='input_47' id='input_27_47' type='text' value='' class='medium'  aria-describedby=\"gfield_description_27_47\" tabindex='48'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_27_45\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Avez-vous des enfants d&#039;une relation pr\u00e9c\u00e9dente?*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_27_45'>\n\t\t\t<li class='gchoice gchoice_27_45_0'>\n\t\t\t\t<input name='input_45' type='radio' value='Oui'  id='choice_27_45_0' tabindex='49'   \/>\n\t\t\t\t<label for='choice_27_45_0' id='label_27_45_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_27_45_1'>\n\t\t\t\t<input name='input_45' type='radio' value='Non'  id='choice_27_45_1' tabindex='50'   \/>\n\t\t\t\t<label for='choice_27_45_1' id='label_27_45_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_27_48\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_48'>\u00c2ge(s):*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_27_48'>\u00c9crire \"N\/A\" si non applicable<\/div><div class='ginput_container ginput_container_text'><input name='input_48' id='input_27_48' type='text' value='' class='medium'  aria-describedby=\"gfield_description_27_48\" tabindex='51'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_27_87\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Votre partenaire a-t-il des enfants d&#039;une relation pr\u00e9c\u00e9dente?*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_27_87'>\n\t\t\t<li class='gchoice gchoice_27_87_0'>\n\t\t\t\t<input name='input_87' type='radio' value='Oui'  id='choice_27_87_0' tabindex='52'   \/>\n\t\t\t\t<label for='choice_27_87_0' id='label_27_87_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_27_87_1'>\n\t\t\t\t<input name='input_87' type='radio' value='Non'  id='choice_27_87_1' tabindex='53'   \/>\n\t\t\t\t<label for='choice_27_87_1' id='label_27_87_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_27_88\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_88'>\u00c2ge(s):*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_27_88'>\u00c9crire \"N\/A\" si non applicable<\/div><div class='ginput_container ginput_container_text'><input name='input_88' id='input_27_88' type='text' value='' class='medium'  aria-describedby=\"gfield_description_27_88\" tabindex='54'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_27_46\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Votre partenaire est-elle pr\u00e9sentement enceinte?*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_27_46'>\n\t\t\t<li class='gchoice gchoice_27_46_0'>\n\t\t\t\t<input name='input_46' type='radio' value='Oui (Si oui, \u00e9crivez la date pr\u00e9vue ci-dessous)'  id='choice_27_46_0' tabindex='55'   \/>\n\t\t\t\t<label for='choice_27_46_0' id='label_27_46_0' class='gform-field-label gform-field-label--type-inline'>Oui (Si oui, \u00e9crivez la date pr\u00e9vue ci-dessous)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_27_46_1'>\n\t\t\t\t<input name='input_46' type='radio' value='Non'  id='choice_27_46_1' tabindex='56'   \/>\n\t\t\t\t<label for='choice_27_46_1' id='label_27_46_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_27_49\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_49'>Date pr\u00e9vue de la naissance si le partenaire est enceinte<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_27_49' type='text' value='' class='medium'   tabindex='57'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_27_50\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Contraception<\/h2><\/li><li id=\"field_27_51\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Quelle m\u00e9thode de contraception utilisez-vous?*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_27_51'><li class='gchoice gchoice_27_51_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.1' type='checkbox'  value='Pilules anti contraceptives'  id='choice_27_51_1' tabindex='58'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_51_1' id='label_27_51_1' class='gform-field-label gform-field-label--type-inline'>Pilules anti contraceptives<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_51_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.2' type='checkbox'  value='Condom'  id='choice_27_51_2' tabindex='59'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_51_2' id='label_27_51_2' class='gform-field-label gform-field-label--type-inline'>Condom<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_51_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.3' type='checkbox'  value='Diaphragme'  id='choice_27_51_3' tabindex='60'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_51_3' id='label_27_51_3' class='gform-field-label gform-field-label--type-inline'>Diaphragme<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_51_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.4' type='checkbox'  value='Capsule cervicale'  id='choice_27_51_4' tabindex='61'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_51_4' id='label_27_51_4' class='gform-field-label gform-field-label--type-inline'>Capsule cervicale<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_51_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.5' type='checkbox'  value='IUD'  id='choice_27_51_5' tabindex='62'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_51_5' id='label_27_51_5' class='gform-field-label gform-field-label--type-inline'>IUD<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_51_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.6' type='checkbox'  value='Depoprovera'  id='choice_27_51_6' tabindex='63'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_51_6' id='label_27_51_6' class='gform-field-label gform-field-label--type-inline'>Depoprovera<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_51_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.7' type='checkbox'  value='Ligation des trompes'  id='choice_27_51_7' tabindex='64'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_51_7' id='label_27_51_7' class='gform-field-label gform-field-label--type-inline'>Ligation des trompes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_51_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.8' type='checkbox'  value='Rythme'  id='choice_27_51_8' tabindex='65'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_51_8' id='label_27_51_8' class='gform-field-label gform-field-label--type-inline'>Rythme<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_51_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.9' type='checkbox'  value='M\u00e9thode de retrait'  id='choice_27_51_9' tabindex='66'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_51_9' id='label_27_51_9' class='gform-field-label gform-field-label--type-inline'>M\u00e9thode de retrait<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_51_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.11' type='checkbox'  value='Autre (veuillez sp\u00e9cifier)'  id='choice_27_51_11' tabindex='67'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_51_11' id='label_27_51_11' class='gform-field-label gform-field-label--type-inline'>Autre (veuillez sp\u00e9cifier)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_27_52\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_52'>Si &quot;Autre&quot; veuillez sp\u00e9cifier la m\u00e9thode:<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_27_52' type='text' value='' class='medium'   tabindex='68'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_27_11\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Historique m\u00e9dical<\/h2><\/li><li id=\"field_27_53\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Veuillez cocher chaque cases s&#039;appliquant \u00e0 votre \u00e9tat: (Cochez toutes celles appliquant)*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_27_53'><li class='gchoice gchoice_27_53_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.1' type='checkbox'  value='Douleur ou pression dans les testicules ou l&#039;a\u00eene'  id='choice_27_53_1' tabindex='69'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_53_1' id='label_27_53_1' class='gform-field-label gform-field-label--type-inline'>Douleur ou pression dans les testicules ou l'a\u00eene<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_53_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.2' type='checkbox'  value='Probl\u00e8mes de saignement (Incluant des pr\u00e9c\u00e9dents familiaux)'  id='choice_27_53_2' tabindex='70'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_53_2' id='label_27_53_2' class='gform-field-label gform-field-label--type-inline'>Probl\u00e8mes de saignement (Incluant des pr\u00e9c\u00e9dents familiaux)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_53_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.3' type='checkbox'  value='D\u00e9pression'  id='choice_27_53_3' tabindex='71'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_53_3' id='label_27_53_3' class='gform-field-label gform-field-label--type-inline'>D\u00e9pression<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_53_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.4' type='checkbox'  value='Epilepsie'  id='choice_27_53_4' tabindex='72'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_53_4' id='label_27_53_4' class='gform-field-label gform-field-label--type-inline'>Epilepsie<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_53_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.5' type='checkbox'  value='H\u00e9patite A, B, C'  id='choice_27_53_5' tabindex='73'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_53_5' id='label_27_53_5' class='gform-field-label gform-field-label--type-inline'>H\u00e9patite A, B, C<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_53_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.6' type='checkbox'  value='Prostatite'  id='choice_27_53_6' tabindex='74'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_53_6' id='label_27_53_6' class='gform-field-label gform-field-label--type-inline'>Prostatite<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_53_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.7' type='checkbox'  value='Diab\u00e8te'  id='choice_27_53_7' tabindex='75'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_53_7' id='label_27_53_7' class='gform-field-label gform-field-label--type-inline'>Diab\u00e8te<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_53_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.8' type='checkbox'  value='Sida'  id='choice_27_53_8' tabindex='76'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_53_8' id='label_27_53_8' class='gform-field-label gform-field-label--type-inline'>Sida<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_53_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.9' type='checkbox'  value='Verrues g\u00e9nitales'  id='choice_27_53_9' tabindex='77'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_53_9' id='label_27_53_9' class='gform-field-label gform-field-label--type-inline'>Verrues g\u00e9nitales<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_53_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.11' type='checkbox'  value='Herp\u00e8s'  id='choice_27_53_11' tabindex='78'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_53_11' id='label_27_53_11' class='gform-field-label gform-field-label--type-inline'>Herp\u00e8s<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_53_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.12' type='checkbox'  value='Blessure ou traumatisme scrotale ou testiculaire'  id='choice_27_53_12' tabindex='79'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_53_12' id='label_27_53_12' class='gform-field-label gform-field-label--type-inline'>Blessure ou traumatisme scrotale ou testiculaire<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_53_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.13' type='checkbox'  value='Testicules non descendus'  id='choice_27_53_13' tabindex='80'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_53_13' id='label_27_53_13' class='gform-field-label gform-field-label--type-inline'>Testicules non descendus<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_53_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.14' type='checkbox'  value='Ant\u00e9c\u00e9dent d&#039;\u00e9vanouissement d\u00fb \u00e0 une intervention m\u00e9dicale ou \u00e0 une injection'  id='choice_27_53_14' tabindex='81'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_53_14' id='label_27_53_14' class='gform-field-label gform-field-label--type-inline'>Ant\u00e9c\u00e9dent d'\u00e9vanouissement d\u00fb \u00e0 une intervention m\u00e9dicale ou \u00e0 une injection<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_53_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.15' type='checkbox'  value='\u00cates-vous d\u00e9rang\u00e9 par une bande serr\u00e9e sur le dessous de votre p\u00e9nis causant de la douleur ou des saignements pendant les relations sexuelles?'  id='choice_27_53_15' tabindex='82'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_53_15' id='label_27_53_15' class='gform-field-label gform-field-label--type-inline'>\u00cates-vous d\u00e9rang\u00e9 par une bande serr\u00e9e sur le dessous de votre p\u00e9nis causant de la douleur ou des saignements pendant les relations sexuelles?<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_53_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.16' type='checkbox'  value='Avez-vous d\u00e9j\u00e0 envisag\u00e9 d&#039;avoir une circoncision pour des raisons m\u00e9dicales ou personnelles?'  id='choice_27_53_16' tabindex='83'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_53_16' id='label_27_53_16' class='gform-field-label gform-field-label--type-inline'>Avez-vous d\u00e9j\u00e0 envisag\u00e9 d'avoir une circoncision pour des raisons m\u00e9dicales ou personnelles?<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_53_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.17' type='checkbox'  value='Autre (veuillez sp\u00e9cifier)'  id='choice_27_53_17' tabindex='84'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_53_17' id='label_27_53_17' class='gform-field-label gform-field-label--type-inline'>Autre (veuillez sp\u00e9cifier)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_53_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.18' type='checkbox'  value='AUCUNE DE CES R\u00c9PONSES'  id='choice_27_53_18' tabindex='85'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_53_18' id='label_27_53_18' class='gform-field-label gform-field-label--type-inline'>AUCUNE DE CES R\u00c9PONSES<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_27_54\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_54'>Si &quot;autre&quot; veuillez sp\u00e9cifier:<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_27_54' type='text' value='' class='medium'   tabindex='86'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_27_25\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Historique chirurgical<\/h2><\/li><li id=\"field_27_57\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Veuillez v\u00e9rifier si vous avez eu l&#039;une des situations suivantes:*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_27_57'><li class='gchoice gchoice_27_57_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.1' type='checkbox'  value='Hernie inguinale ou sportive dans l&#039;aine'  id='choice_27_57_1' tabindex='87'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_57_1' id='label_27_57_1' class='gform-field-label gform-field-label--type-inline'>Hernie inguinale ou sportive dans l'aine<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_57_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.2' type='checkbox'  value='Une premi\u00e8re vasectomie'  id='choice_27_57_2' tabindex='88'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_57_2' id='label_27_57_2' class='gform-field-label gform-field-label--type-inline'>Une premi\u00e8re vasectomie<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_57_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.3' type='checkbox'  value='Renversement de vasectomie'  id='choice_27_57_3' tabindex='89'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_57_3' id='label_27_57_3' class='gform-field-label gform-field-label--type-inline'>Renversement de vasectomie<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_57_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.4' type='checkbox'  value='La chirurgie scrotale ou testiculaire (y compris l&#039;abaissement des testicules non descendus)'  id='choice_27_57_4' tabindex='90'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_57_4' id='label_27_57_4' class='gform-field-label gform-field-label--type-inline'>La chirurgie scrotale ou testiculaire (y compris l'abaissement des testicules non descendus)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_27_57_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.5' type='checkbox'  value='AUCUNE DE CES R\u00c9PONSES'  id='choice_27_57_5' tabindex='91'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_57_5' id='label_27_57_5' class='gform-field-label gform-field-label--type-inline'>AUCUNE DE CES R\u00c9PONSES<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_27_55\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">M\u00e9dications<\/h2><\/li><li id=\"field_27_58\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_58'>Veuillez \u00e9num\u00e9rer tous les m\u00e9dicaments que vous prenez, y compris le nom et la posologie: (y compris l&#039;aspirine, Advil, d&#039;autres anti-inflammatoires)*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_27_58'>\u00c9crivez \"N\/A\" si non applicable<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_58' id='input_27_58' class='textarea medium' tabindex='92' aria-describedby=\"gfield_description_27_58\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_27_56\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Allergies<\/h2><\/li><li id=\"field_27_59\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_59'>Veuilez d\u00e9crire vos allergies*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_27_59'>\u00c9crivez \"N\/A\" si non applicable<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_59' id='input_27_59' class='textarea medium' tabindex='93' aria-describedby=\"gfield_description_27_59\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_27_95\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Taille et poids<\/h2><\/li><li id=\"field_27_80\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_80'>Tour de taille*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_80' id='input_27_80' type='text' value='' class='medium'   tabindex='94'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_27_90\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_90'>Votre taille*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_90' id='input_27_90' type='text' value='' class='medium'   tabindex='95'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_27_91\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_91'>Votre poids*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_91' id='input_27_91' type='text' value='' class='medium'   tabindex='96'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_27_83\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Service Premium<\/h2><\/li><li id=\"field_27_84\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Choisirez vous le service Premium? (Fortement recommand\u00e9)*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_27_84'>Principaux avantages de la Vasectomie Premium\n\n1) Anesth\u00e9sie sans aiguille pour am\u00e9liorer votre confort.\n2) Toutes les fournitures dont vous aurez besoin avant et apr\u00e8s votre vasectomie pr\u00e9vu pour vous comme votre temps est pr\u00e9cieux. \n3) Toutes vos visites de suivi se feront par t\u00e9l\u00e9phone. Tout cela vous fera economiser de temps.\n(Voir <a target=\"_blank\" href=\"\/fr\/vasectomie\/prix\/\">Prix d'une vasectomie<\/a> Pour plus de d\u00e9tails)<\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_27_84'>\n\t\t\t<li class='gchoice gchoice_27_84_0'>\n\t\t\t\t<input name='input_84' type='radio' value='Oui, je voudrais le service Premium'  id='choice_27_84_0' tabindex='97'   \/>\n\t\t\t\t<label for='choice_27_84_0' id='label_27_84_0' class='gform-field-label gform-field-label--type-inline'>Oui, je voudrais le service Premium<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_27_84_1'>\n\t\t\t\t<input name='input_84' type='radio' value='Non, je ne veux pas le service Premium'  id='choice_27_84_1' tabindex='98'   \/>\n\t\t\t\t<label for='choice_27_84_1' id='label_27_84_1' class='gform-field-label gform-field-label--type-inline'>Non, je ne veux pas le service Premium<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_27_33\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Accord de vasectomie<\/h2><div class='gsection_description' id='gfield_description_27_33'><span style=\"color:red\">Vous devez consentir \u00e0 ce qui suit:\n<\/span><\/div><\/li><li id=\"field_27_34\" class=\"gfield gfield--type-checkbox gfield--type-choice ginput_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_27_34'><li class='gchoice gchoice_27_34_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.1' type='checkbox'  value='J&#039;ai lu toutes les informations sur le site concernant la vasectomie sans scalpel*'  id='choice_27_34_1' tabindex='99'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_34_1' id='label_27_34_1' class='gform-field-label gform-field-label--type-inline'>J'ai lu toutes les informations sur le site concernant la vasectomie sans scalpel*<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_27_89\" class=\"gfield gfield--type-checkbox gfield--type-choice ginput_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_27_89'><li class='gchoice gchoice_27_89_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_89.1' type='checkbox'  value='Je comprends qu&#039;une r\u00e9f\u00e9rence d&#039;un m\u00e9decin de famille est n\u00e9cessaire afin de r\u00e9server ma proc\u00e9dure (le m\u00e9decin sans rendez-vous est parfaitement bien si vous ne l&#039;avez pas).*'  id='choice_27_89_1' tabindex='100'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_89_1' id='label_27_89_1' class='gform-field-label gform-field-label--type-inline'>Je comprends qu'une r\u00e9f\u00e9rence d'un m\u00e9decin de famille est n\u00e9cessaire afin de r\u00e9server ma proc\u00e9dure (le m\u00e9decin sans rendez-vous est parfaitement bien si vous ne l'avez pas).*<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_27_39\" class=\"gfield gfield--type-checkbox gfield--type-choice ginput_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_27_39'><li class='gchoice gchoice_27_39_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.1' type='checkbox'  value='Je comprends toutes les complications potentielles de la chirurgie incluant l&#039;h\u00e9matome scrotale, l&#039;infection, l&#039;\u00e9pididymite, le granulome de sperme, le syndrome de douleur post-vasectomie et l&#039;\u00e9chec tardif.*'  id='choice_27_39_1' tabindex='101'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_39_1' id='label_27_39_1' class='gform-field-label gform-field-label--type-inline'>Je comprends toutes les complications potentielles de la chirurgie incluant l'h\u00e9matome scrotale, l'infection, l'\u00e9pididymite, le granulome de sperme, le syndrome de douleur post-vasectomie et l'\u00e9chec tardif.*<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_27_37\" class=\"gfield gfield--type-checkbox gfield--type-choice ginput_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_27_37'><li class='gchoice gchoice_27_37_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.1' type='checkbox'  value='Je sais que je ne dois pas boire d&#039;alcool pendant 48 heures avant et  48 heures apr\u00e8s la proc\u00e9dure.*'  id='choice_27_37_1' tabindex='102'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_37_1' id='label_27_37_1' class='gform-field-label gform-field-label--type-inline'>Je sais que je ne dois pas boire d'alcool pendant 48 heures avant et  48 heures apr\u00e8s la proc\u00e9dure.*<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_27_36\" class=\"gfield gfield--type-checkbox gfield--type-choice ginput_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_27_36'><li class='gchoice gchoice_27_36_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.1' type='checkbox'  value='Je sais que je ne dois pas prendre de l&#039;aspirine (ASA), des anticoagulants (warfarine) ou des anti-inflammatoires (AINS) comme l&#039;ibuprof\u00e8ne, Advil, Motrin, Aleve, etc. 7 jours avant la proc\u00e9dure et pendant 2 jours apr\u00e8s.*'  id='choice_27_36_1' tabindex='103'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_36_1' id='label_27_36_1' class='gform-field-label gform-field-label--type-inline'>Je sais que je ne dois pas prendre de l'aspirine (ASA), des anticoagulants (warfarine) ou des anti-inflammatoires (AINS) comme l'ibuprof\u00e8ne, Advil, Motrin, Aleve, etc. 7 jours avant la proc\u00e9dure et pendant 2 jours apr\u00e8s.*<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_27_74\" class=\"gfield gfield--type-checkbox gfield--type-choice ginput_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_27_74'><li class='gchoice gchoice_27_74_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.1' type='checkbox'  value='J&#039;ai discut\u00e9 d&#039;une vasectomie avec mon partenaire et il est favorable \u00e0 ma d\u00e9cision (s&#039;il vous pla\u00eet appelez notre bureau pour discuter si ce n&#039;est pas le cas).*'  id='choice_27_74_1' tabindex='104'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_74_1' id='label_27_74_1' class='gform-field-label gform-field-label--type-inline'>J'ai discut\u00e9 d'une vasectomie avec mon partenaire et il est favorable \u00e0 ma d\u00e9cision (s'il vous pla\u00eet appelez notre bureau pour discuter si ce n'est pas le cas).*<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_27_61\" class=\"gfield gfield--type-checkbox gfield--type-choice ginput_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_27_61'><li class='gchoice gchoice_27_61_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.1' type='checkbox'  value='Je comprends que si je r\u00e9serve ma vasectomie et que je ne me pr\u00e9sente pas OU si j&#039;annule ma vasectomie avec un pr\u00e9avis de moins de 2 jours ouvrables OU si je fais quelque chose m&#039;ayant clairement \u00e9t\u00e9 contre indiqu\u00e9, (c.-\u00e0-d. durant la Semaine pr\u00e9c\u00e9dent l&#039;op\u00e9ration), je serai tenu de payer des frais d&#039;annulation de 150 $.*'  id='choice_27_61_1' tabindex='105'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_61_1' id='label_27_61_1' class='gform-field-label gform-field-label--type-inline'>Je comprends que si je r\u00e9serve ma vasectomie et que je ne me pr\u00e9sente pas OU si j'annule ma vasectomie avec un pr\u00e9avis de moins de 2 jours ouvrables OU si je fais quelque chose m'ayant clairement \u00e9t\u00e9 contre indiqu\u00e9, (c.-\u00e0-d. durant la Semaine pr\u00e9c\u00e9dent l'op\u00e9ration), je serai tenu de payer des frais d'annulation de 150 $.*<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_27_38\" class=\"gfield gfield--type-checkbox gfield--type-choice ginput_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_27_38'><li class='gchoice gchoice_27_38_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.1' type='checkbox'  value='J&#039;ai lu la section sur les frais et je comprends que Sant\u00e9 NB ne couvre que les co\u00fbts de base d&#039;une vasectomie. Je comprends que le forfait Premium est facultatif mais fortement recommand\u00e9 pour un confort et une commodit\u00e9 am\u00e9lior\u00e9s, car il s&#039;agit d&#039;une redevance unique pour une proc\u00e9dure unique dans la vie.*'  id='choice_27_38_1' tabindex='106'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_27_38_1' id='label_27_38_1' class='gform-field-label gform-field-label--type-inline'>J'ai lu la section sur les frais et je comprends que Sant\u00e9 NB ne couvre que les co\u00fbts de base d'une vasectomie. Je comprends que le forfait Premium est facultatif mais fortement recommand\u00e9 pour un confort et une commodit\u00e9 am\u00e9lior\u00e9s, car il s'agit d'une redevance unique pour une proc\u00e9dure unique dans la vie.*<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_27_96\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_27_96'>Email<\/label><div class='gfield_description' id='gfield_description_27_96'>Ce champ n\u2019est utilis\u00e9 qu\u2019\u00e0 des fins de validation et devrait rester inchang\u00e9.<\/div><div class='ginput_container'><input name='input_96' id='input_27_96' type='text' value='' autocomplete='new-password'\/><\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_27' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='ENVOYER' tabindex='107' \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_27' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_27' id='gform_theme_27' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_27' id='gform_style_settings_27' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_27' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='27' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_27' value='WyJbXSIsImI3YWVlMWQ5YmY5MGQxMWQ2NmJhZTdmYWJlYmIzNGZjIl0=' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_27' id='gform_target_page_number_27' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_27' id='gform_source_page_number_27' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div><script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 27, 'https:\/\/gentleproceduresnb.ca\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_27').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_27');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_27').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! 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